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Jos de Blok – Director, Buurtzorg Netherlands

Clinical staff are the power behind healthcare delivery, so any attempt at transformation needs their full commitment. The success of the Virginia Mason Medical Center in the US has been built upon high workforce engagement, giving people an active role in the creation and delivery of its vision.

Productivity often increases when clinicians are given freedom to develop their professional activity. Buurtzorg, a home care organization in the Netherlands, has achieved tremendous success by empowering its nurses to provide a full range of care to patients, with very little management direction and a small support team: 45 back office staff for a workforce of 8000 nurses.

Such hierarchical delayering may be beyond many organizations, but sets a benchmark of what can be accomplished when staff are trusted to do the best for their patients. The results suggest that, rather than help, managerial systems may actually hinder productivity and impair employee satisfaction.

Although financial reward typically is a motivator in most sectors, healthcare workers arguably have an almost unique attachment to their patients that goes beyond money. Indeed, many would describe their career as a vocation rather than a job, with a commitment that transcends any particular workplace. Some healthcare leaders may wrongly interpret such a mentality as a lack of loyalty to a particular organization, hence the tendency for clinicians to be seen as ‘difficult’ employees. Rather than question their commitment, managers should utilize this natural motivation; without the health professionals on their side, change will be very difficult.

Richard Bohmer is an advocate of uncovering and building on intrinsic professional commitments to care. He argues that a world-weary cynicism has crept into doctors’ world view, depriving organizations of a vital source of energy for change. Richard singled out mid-level clinical leaders as a neglected group with great potential to positively influence transformation.

As KPMG’s David Ikkersheim asserts, the concept of ‘the workforce’ now needs to be extended to include patients, caregivers and communities, all of whom add value to the continuum of care. “Most healthcare organizations talk about being patient-centered, but are they really? By embracing patients as part of the workforce, there is a great potential to improve efficiency and quality of care.” This means taking time to understand the motivations of patients, who may need some training to maximize the value they bring. Such an approach is already happening in some emerging countries such as Nigeria.

Case study – Trust and autonomy: Buurtzorg (NL)

The Dutch word Buurtzorg means ‘neighborhood care,’ and this home care provider has a nationwide team of 8000 nurses treating 70,000 patients a year across the Netherlands. Buurtzorg empowers its staff to deliver all the care that patients need (rather than use nursing assistants or cleaners), allowing each nurse to organize their own work, make personal judgments and build strong community relationships. They have a turnover of 260 million Euros, but a back office staff of just 45 – none of which are designated as managers.

Each neighborhood has a small self-steering team which focuses on their locality. The nurses are generalists, concentrated on outcomes and supported by handheld technology that removes the complexity from the place of care. Such responsibility has proved highly liberating. Freed from excessive hierarchical rules, the nurses have been extremely efficient, reducing the hours of care per patient by 50 percent, while improving quality. Both patient and employee satisfaction levels have risen dramatically, absenteeism is low and, in 2011, Buurtzorg was chosen as the Dutch employer of the year.

The lean back office and flat structure allow the organization to keep costs low. And in a tight labor market, the company continues to attract new nurses keen to work in a fulfilling environment.